Management of major obstetric hemorrhage prior to peripartum hysterectomy and outcomes across nine European countries

Introduction
Peripartum hysterectomy is applied as a surgical intervention of last resort for major obstetric hemorrhage. It is performed in an emergency setting except for women with a strong suspicion of placenta accreta spectrum (PAS), where it may be anticipated before cesarean section. The aim of this study was to compare management strategies in the case of obstetric hemorrhage leading to hysterectomy, between nine European countries participating in the International Network of Obstetric Survey Systems (INOSS), and to describe pooled maternal and neonatal outcomes following peripartum hysterectomy.

Material and methods
We merged data from nine nationwide or multi‐regional obstetric surveillance studies performed in Belgium, Denmark, Finland, France, Italy, the Netherlands, Slovakia, Sweden and the UK collected between 2004 and 2016. Hysterectomies performed from 22 gestational weeks up to 48 h postpartum due to obstetric hemorrhage were included. Stratifying women with and without PAS, procedures performed in the management of obstetric hemorrhage prior to hysterectomy between countries were counted and compared. Prevalence of maternal mortality, complications after hysterectomy and neonatal adverse events (stillbirth or neonatal mortality) were calculated.

Results
A total of 1302 women with peripartum hysterectomy were included. In women without PAS who had major obstetric hemorrhage leading to hysterectomy, uterotonics administration was lowest in Slovakia (48/73, 66%) and highest in Denmark (25/27, 93%), intrauterine balloon use was lowest in Slovakia (1/72, 1%) and highest in Denmark (11/27, 41%), and interventional radiology varied between 0/27 in Denmark and Slovakia to 11/59 (79%) in Belgium. In women with PAS, uterotonics administration was lowest in Finland (5/16, 31%) and highest in the UK (84/103, 82%), intrauterine balloon use varied between 0/14 in Belgium and Slovakia to 29/103 (28%) in the UK. Interventional radiology was lowest in Denmark (0/16) and highest in Finland (9/15, 60%). Maternal mortality occurred in 14/1226 (1%), the most common complications were hematologic (95/1202, 8%) and respiratory (81/1101, 7%). Adverse neonatal events were observed in 79/1259 (6%) births.

Conclusions
Management of obstetric hemorrhage in women who eventually underwent peripartum hysterectomy varied greatly between these nine European countries. This potentially life‐saving procedure is associated with substantial adverse maternal and neonatal outcome.

Surgical candidacy and treatment initiation among women with cervical cancer at public referral hospitals in Kampala, Uganda: a descriptive cohort study

Objectives This study aimed to report the proportion of women with a new diagnosis of cervical cancer recommended for curative hysterectomy as well as associated factors. We also report recommended treatments by stage and patterns of treatment initiation.

Design This was an observational cohort study. Inperson surveys were followed by a phone call.

Setting Participants were recruited at the two public tertiary care referral hospitals in Kampala, Uganda.

Participants Adult women with a new diagnosis of cervical cancer were eligible: 332 were invited to participate, 268 met the criteria and enrolled, and 255 completed both surveys.

Primary and secondary outcomes measures The primary outcome of interest was surgical candidacy; a secondary outcome was treatment initiation. Descriptive and multivariate statistical analyses examined the associations between predictors and outcomes. Sensitivity analyses were performed to examine outcomes in subgroups, including stage and availability of radiation.

Results Among 268 participants, 76% were diagnosed at an advanced stage (IIB–IVB). In total, 12% were recommended for hysterectomy. In adjusted analysis, living within 15 km of Kampala (OR 3.10, 95% CI 1.20 to 8.03) and prior screening (OR 2.89, 95% CI 1.22 to 6.83) were significantly associated with surgical candidacy. Radiotherapy availability was not significantly associated with treatment recommendations for early-stage disease (IA–IIA), but was associated with recommended treatment modality (chemoradiation vs primary chemotherapy) for locally advanced stage (IIB–IIIB). Most (67%) had started treatment. No demographic or health factor, treatment recommendation, or radiation availability was associated with treatment initiation. Among those recommended for hysterectomy, 55% underwent surgery. Among those who had initiated treatment, 82% started the modality that was recommended.

Conclusion Women presented to public referral centres in Kampala with mostly advanced-stage cervical cancer and few were recommended for surgery. Most were able to initiate treatment. Lack of access to radiation did not significantly increase the proportion of early-stage cancers recommended for hysterectomy.

Surgical management of cervical cancer in a resource‐limited setting: One year of data from the National Cancer Institute, Sri Lanka

Objective
To evaluate the surgical management of cervical cancer without the use of preoperative pelvic imaging in a resource‐limited setting.

Methods
A retrospective study was carried out using clinical records and the ongoing electronic database at the Gynaecological Oncology Unit, National Cancer Institute (Apeksha Hospital), Maharagama, Sri Lanka. Details regarding the radical hysterectomies carried out from January 1, 2019, to December 31, 2019, were retrospectively studied.

Results
Out of nearly 700 patients with cervical cancer admitted during the year 2019, 57 surgically managed radical hysterectomies were included. Of these, seven cases were ineligible and excluded and 50 cases of radical hysterectomies were included for analysis. Mean age was 53.6 ± 9.5 years and median parity was 3 (range 2–4). Of the cases, 94% were found to have no parametrial involvement showing the success of clinical examination in assessing local tumor spread. Overall, 11 (22.0%) were upstaged due to lymph node metastasis that was statistically significant.

Conclusion
Preoperative clinical staging is a practical method in selecting surgically treatable cervical cancer in low‐ and middle‐income countries (LMICs). Combining clinical assessment with comparatively more readily available computed tomography scans could be helpful in triaging patients for treatment of cervical cancer in LMICs.

Gynecological hysterectomy in Northern Tanzania: a cross- sectional study on the outcomes and correlation between clinical and histological diagnoses

Background
Hysterectomy is one of the most common gynaecological procedures performed worldwide. The magnitude of the complications related to hysterectomy and their risk factors are bound to differ based on locations, availability of resources and level of surgical training. Documented complications rates and their correlates are reported from high income countries while data from low- and middle-income countries including Tanzania is scare.
Methods
This was a hospital based cross-sectional study conducted at a tertiary facility in northern Tanzania where 178 women who underwent elective gynecological hysterectomies in the department of obstetrics and gynecology within the study period were enrolled. Logistic regression was performed to determine the association between risk factors and occurrence of surgical complication where p-value of  2 h) (OR 5.02; 95% CI 2.18–11.5). Both uterine fibroid and adenomyosis had good correlation of clinical and histological diagnosis (p-value < 0.001).
Conclusion
Bleeding and blood transfusion were the most common complications observed in this study. Obesity, previous abdominal operation and prolonged duration of operation were the most significant risk factors for the complications. Local tailored interventions to reduce surgical complications of hysterectomy are thus pivotal. Clinicians in this locality should have resources at their disposal to enhance definitive diagnosis attainment before surgical interventions.

Feasibility and Compatibility of Minilaparotomy Hysterectomy in a Low-Resource Setting.

Minilaparotomy hysterectomy (MLH) relies on the simplicity of the traditional open technique of abdominal hysterectomy, imparts cosmesis and faster recovery of laparoscopic hysterectomy yet avoids the long learning curve and cost of expensive setup and instrumentation associated with the minimally invasive approaches, namely, laparoscopy and robotics. In the present study, we tried to ascertain whether the results obtained with MLH can be compared to LAVH in terms of its feasibility, intraoperative variables, and complications. The null hypothesis was that both MLH and LAVH are comparable techniques; thus, where cost and surgeon’s experience are the confining issues, patients can be reassured that MLH gives comparable results.This was a prospective observational study done over a period of two years at a university teaching hospital. A total of 65 patients were recruited, but only 52 (MLH: 27; LAVH: 25) could be included in final analysis. All surgeries were performed by one of the two gynecologists with almost equal surgical competence, and outcomes were compared.MLH is a feasible option for benign gynecological pathologies as none of the patients required increase in the initial incision (4-6 cm). MLH could be done for larger uteri (MLH: 501.30 ± 327.96 g versus LAVH: 216.60 ± 160.01 g; p < 0.001), in shorter duration (MLH: 115.00 ± 21.43 min versus LAVH 172.00 ± 27.91 min; p < 0.001), with comparable blood loss (MLH: 354.63 ±227.96 ml; LAVH: 402.40 ± 224.02 ml; p=0.334), without serious complications when compared to LAVH.The technique of MLH should be mastered and encouraged to be used in low-resource setting to get results comparable to laparoscopic surgery. This trial is registered with NCT03548831.